What is the appropriate management for a patient with left-sided head, neck, and ear pain, and elevated White Blood Cell (WBC) count, who has not responded to oxycodone (Oxycodone) and Toradol (Ketorolac), and has previously received relief with Dilaudid (Hydromorphone)?

From the Guidelines

I do not recommend administering dilaudid 1mg to this patient as a first-line treatment for left-sided head, neck, and ear pain, given the potential risks of opioid use and the availability of alternative pain management options. The patient's history of previous response to dilaudid does not outweigh the risks associated with opioid use, particularly in light of the CDC's clinical practice guideline for prescribing opioids for pain, which emphasizes the importance of multimodal analgesia and nonpharmacologic therapies 1. The guideline recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders and suggests that opioids are not recommended as first-line therapy for many common acute pain conditions, including headaches.

Given that the patient has already been treated with oxycodone and toradol with minimal relief, it is essential to consider alternative pain management options, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, before resorting to opioids. The patient's elevated WBC suggests possible infection or inflammation, and further diagnostic workup, including imaging studies and possibly antibiotics, may be necessary to determine the underlying cause of the symptoms.

The CDC guideline recommends that clinicians work with patients to prevent prolonged opioid use and prescribe opioids only as needed, rather than on a scheduled basis 1. Additionally, the guideline emphasizes the importance of patient education and discussion before starting outpatient opioid therapy, including advising patients about the risks of opioid use disorder, respiratory depression, and death 1. In this case, it is crucial to weigh the potential benefits of dilaudid against the risks and to consider alternative pain management options that may be more effective and safer for the patient.

Some key points to consider in the management of this patient's pain include:

• Using nonopioid pharmacologic and nonpharmacologic therapies as appropriate for the specific condition
• Prescribing immediate-release opioids at the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids
• Maximizing the use of nonopioid therapies and minimizing the use of opioids
• Providing patient education and discussion about the risks and benefits of opioid therapy
• Monitoring the patient's response to treatment and adjusting the pain management plan as needed.

From the FDA Drug Label

Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals Initiating Treatment with Hydromorphone Hydrochloride Tablets Initiate treatment with hydromorphone hydrochloride tablets in a dosing range of 2 mg to 4 mg, orally, every 4 to 6 hours.

The patient is requesting 1mg of dilaudid, which is lower than the recommended initial dose range of 2mg to 4mg. Key considerations for the patient's request include:

• The patient's previous experience with dilaudid, where 1mg was effective
• The patient's current pain level and previous lack of response to other medications, such as oxycodone and toradol
• The need to use the lowest effective dosage for the shortest duration to minimize the risk of adverse reactions and dependence

Given the patient's specific situation and the information provided, a conservative approach would be to consider the patient's request for 1mg of dilaudid, while closely monitoring for signs of excessive sedation and respiratory depression 2. However, it is essential to follow the recommended dosage guidelines and consult with the patient's healthcare provider to determine the best course of treatment 3.

From the Research

Patient's Condition and Medication History

• The patient is experiencing left-sided head, neck, and ear pain, and has been sent by their PCP for high WBC.
• The patient has previously been given oxycodone and toradol, but reports that these medications did not provide adequate pain relief.
• The patient is requesting dilaudid, which they claim has helped them in the past.

Studies on Pain Management and Medication Stability

• A study on muscle relaxants for acute and chronic pain found that the utilization of muscle relaxants varies for treatment of acute and chronic pain 4.
• A study on the microbiological and physicochemical stability of fentanyl, oxycodone, hydromorphone, ketorolac, ramosetron, and ondansetron for intravenous patient-controlled analgesia found that the concentration of ketorolac decreased in more acidic mixtures 5.
• A study comparing morphine, ketorolac, and their combination for postoperative pain found that opioids are more efficacious analgesics than NSAIDs, although adding NSAIDs to the opioid treatment reduces morphine requirements and opioid-related side effects 6.

Considerations for Prescribing Opioids

• A study on recommendations for prescribing opioids for people with traumatic brain injury found that there is a need for careful consideration and monitoring when prescribing opioids for this high-risk group 7.
• A study on the association of combination opioid, benzodiazepine, and muscle relaxant usage with emergency department visits found that concurrent opioid and benzodiazepine use, as well as opioid, benzodiazepine, and muscle relaxant use, are linked to increased adverse events and emergency department visits 8.